Q. My wife and I do not have long-term care insurance. We hear that Medicare coverage for nursing homes is limited. Do you have any tips on how to make the most of it?
A. Sure. Medicare coverage for nursing home stays is really designed for short-term convalescence following a hospital stay. But if you know the rules you can get the most out of this limited coverage:
Basic rule: Not To Exceed 100 Days: Medicare will only cover up to 100 days in a nursing home, but only after a 3-day hospital stay. Days 1–20 are covered 100%, while days 21–100 have a patient co-pay of $144.50 per day (unless you have a Medicare Supplement Plan). Coverage is available only if you are discharged to a skilled nursing facility (“SNF”), so if you are discharged to an assisted-living facility the cost of care is your own responsibility. Many clients misunderstood this 100 day rule: It is a maximum number of days, and most individuals actually receive LESS THAN 100 days of Medicare Coverage.
The 3 Day Hospital Stay: To trigger coverage, you must have been first admitted into a hospital for at least 3 days. Thus, direct entry from home to the SNF will generally not qualify. Tip: if SNF care appears likely after discharge, consider going to the SNF directly upon hospital discharge, or at least within 30 days of discharge. Note: if you are enrolled in a Medicare Advantage Plan, a prior 3-day hospital state may not be required. Check your plan.
The “Observation Status” Trap: If you go to the emergency room and are maintained in “observation status”, that time period does not count toward the 3 day requirement. You must actually have been “admitted” into the hospital. Unbeknownst to ER patients, they are sometimes kept in observation status for days. Tip: if it appears that you may need follow-up care in a SNF, check your hospital status and make sure you have been formally “admitted”.
The “3 Midnights Rule”: The 3 days are counted by reference to stays past midnight of each qualifying day. Example: if you are admitted on Monday at 11:50 PM and discharged on Wednesday evening at 8 PM, will not have met the 3-day requirement. But if you remain until Thursday morning at 8 AM, you will have met that requirement. Tip: if you believe you are about to be discharged before the 3rd midnight, ask your doctor to extend your stay if otherwise medically justified. Sometimes just a few more hours can secure coverage.
Must Need Skilled Therapy: In order to receive the full 100 days, you must need skilled medical therapy on a daily basis, e.g. wound care, intubation, or rehabilitation. If you only need help with activities like bathing, toileting, or eating (“custodial care”), you will NOT qualify for Medicare coverage even if you have not used up your 100 days. Tip: make sure you request and fully cooperate with prescribed skilled therapies while in the SNF.
“Medical Improvement Standard” Often Misapplied: If you hear the SNF staff describe your Medicare days as about to end because your improvement has “plateaued”, they are likely applying an incorrect standard. Medical improvement is no longer required. The correct standard is whether ongoing therapies in the SNF are needed to help you to “attain” or “maintain” your highest level of function, i.e. to help you avoid “back sliding”. Tip: Ask your therapists and/or physician if you would be at risk of losing functionality if therapies were stopped and, if so, ask them to note that in your chart. For more see the following article: “Medicare Available For Chronic Conditions But Word Slow To Get Out.”
Expedited Appeal: If you receive a notice that your benefits are about to be terminated before the 100 days, request an appeal. Appeals are decided by an outside agency, are often resolved in one day and many are won. Tip: make sure your medical chart contains a statement by the medical providers that continued therapies are necessary to help you “maintain” your highest level of function.
Knowledge of the rules and patient advocacy can go a long way toward ensuring Medicare coverage for the full 100 days. However, extended stays will require private payment or application for a Medi-Cal subsidy. Many middle income persons are surprised to learn that a Medi-Cal subsidy may be within reach at time of need.
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Reference: See the following publication from the Medicare website: “Medicare Coverage for Skilled Nursing Facility Care”